Empagliflozin mitigates endothelial inflammation and attenuates endoplasmic reticulum stress signaling caused by sustained glycocalyx disruption

The disruption of the endothelial cell (EC) glycocalyx (GCX) leads to cellular dysfunction promoting inflammation and cardiovascular disease progression. Recent studies have shown that empagliflozin (EMPA; Jardiance), a sodium-glucose cotransporter 2 inhibitor used in the treatment of type 2 diabetes, can improve EC functions impacted by GCX disruption although the exact cellular mechanisms remain to be elucidated. In this study, the effect of EMPA on EC inflammatory response induced by sustained GCX disruption was investigated. Human aortic ECs were cultured under shear (10 dyne/cm2) for 24 h with or without sustained degradation of heparan sulfate (HS). HS degradation increased inflammatory cell adhesion to ECs. EMPA (50 μM) normalized adhesion levels under sustained HS degradation. Protein expressions of eNOS, phospho-eNOS Ser1177 and ICAM-1 remained unchanged between conditions. Transcriptome analysis revealed the induction of the unfolded protein response (UPR) through the increased expression of ATF3, ATF4, DDIT3 (CHOP), EIF2AK3 (PERK), HSPA5 (Grp78), PPP1R15A (GADD34) and TRIB3 which was in part downregulated by EMPA. mRNA and protein expression of thioredoxin interacting protein (TXNIP) was also downregulated by EMPA. Mitigation of oxidative stress with N-Acetyl-l-cysteine resulted in similar reduction in inflammatory cell adhesion compared to EMPA which could indicate a potential mechanism by which EMPA normalized the inflammatory response. In conclusion, this study demonstrated the potential of EMPA to resolve the inflammatory response of ECs caused by sustained GCX disruption while altering UPR signaling under endoplasmic reticulum stress.

The endothelial glycocalyx (GCX) is a glycosaminoglycan and proteoglycan-rich functional layer lining the endothelium which promotes homeostasis through its role as a mechanosensor and as a barrier to inflammatory cell attachment. Disruption of the GCX in pathological conditions such as type 2 diabetes (T2D) and atherosclerosis 1,2 causes endothelial cell (EC) dysfunction and thus, leads to cardiovascular disease progression. In particular, in vitro and in vivo degradation of heparan sulfate (HS), the main component of EC GCX, has been shown to impair shear-regulated nitric oxide (NO) production and promote adhesion of inflammatory cells [3][4][5] . Given its central role in EC homeostasis, the GCX is considered a potential therapeutic target to prevent or alleviate EC dysfunction and therefore benefit clinical outcomes 6,7 .
Empagliflozin (EMPA; Jardiance ® ) belongs to the sodium-glucose cotransporter 2 inhibitor (SGLT2i) class of drugs used in the treatment of T2D and more recently heart failure. This class has emerged as a promising new therapy for cardiovascular diseases as treatment with a SGLT2i has shown impressive beneficial outcomes in recent clinical trials (e.g. EMPA-REG OUTCOME (NCT01131676) 8 , DAPA-HF (NCT03036124) and EMPEROR-Reduced (NCT03057977) 9,10 ). Among these, the EMPA-REG OUTCOME trial demonstrated significant reductions in the rate of hospitalization for heart failure and cardiovascular death in T2D patients treated with EMPA when compared with placebo 8 . Subsequent animal studies have suggested pleiotropy and extended protective effects by EMPA to atherosclerosis 11 , heart failure 12,13 and ischemia-reperfusion injury 14 in non-diabetic conditions, suggesting that the cardiovascular protection is not achieved solely through glycosuria.

ICAM-1 and eNOS are not implicated in the HS independent EMPA anti-inflammatory response.
The expression of eNOS and ICAM-1 were assessed to characterize the inflammatory response induced by sustained HS degradation and their potential role in the recovery effect provided by EMPA. After 24 h of culture, eNOS expression in all static and shear TNF-α + conditions were reduced compared to TNF-α -controls (Fig. 2a, *p < 0.001). There was no observed effect of EMPA nor degradation on eNOS expression. Shear significantly increased the phospho-eNOS Ser1177 levels compared to the static control in absence of TNF-α (Fig. 2b, CTL TNF-α -shear vs CTL TNF-α -static # p < 0.001). TNF-α stimulation impaired the shear-induced increase of phospho-eNOS Ser1177 to similar levels in all shear conditions suggesting reduced eNOS activation (*p < 0.001). Again, no significant impact on phospho-eNOS Ser1177 caused by EMPA or degradation were found. Similarly, TNF-α induced the expression of ICAM-1 to similar levels in all conditions (Fig. 2c, *p < 0.001) with no significant effect of shear, EMPA or degradation. Interestingly, the phospho-eNOS Ser1177/total eNOS ratio remained unchanged with or without TNF-α in shear condition while significantly higher ratios were found in static culture (Fig. 2d, *p < 0.01). Taken together, these results suggest that the activation of eNOS and the expression of ICAM-1 are not directly implicated in the HS independent recovery of EC dysfunction by EMPA.
The induction of the unfolded protein response caused by sustained HS degradation is partially restored by EMPA. To explore the possible signaling pathways impacted by the sustained degradation of HS and EMPA beyond the traditional mechanobiology and anti-inflammatory role of the GCX, a genome-wide transcriptome analysis was performed. We sought to better understand the mechanisms by which EMPA prevents the increased inflammatory response triggered by the sustained HS degradation under shear culture. EC dysfunction associated genes were screened and grouped to identify the signaling pathways involved based on their fold changes.
Sustained HS degradation under shear caused the upregulation of genes related to the unfolded protein response (UPR) and the C/EBP homologous protein (CHOP) transcriptional factors suggesting that ECs were subjected to endoplasmic reticulum (ER) stress. As such, activating transcription factor 3 (ATF3), DNA-damageinducible transcript 3 (DDIT3; CHOP) and tribbles homolog 3 (TRIB3) were significantly upregulated under HS degradation compared to the control (Fig. 3a, sDEG vs CTL *p < 0.001). The activation of the UPR was also apparent by the upregulation of the activating transcription factor 4 (ATF4), the eukaryotic translation initiation factor 2 α kinase 3 (EIF2AK3; PERK), the ER chaperon protein Grp78 (HSPA5) and the growth arrest and DNA damage-inducible protein GADD34 (PPP1R15A) (Fig. 3b, sDEG vs CTL *p < 0.001). EMPA significantly reduced the expression of ATF3, DDIT3, HSPA5, PPP1R15A and TRIB3 under HS degradation (sDEG-EMPA vs sDEG # p < 0.001, $ p < 0.01, % p < 0.05). The transcriptional regulation induced by sustained HS degradation and EMPA appeared to be mediated mainly through the PKR-like ER kinase (PERK, EIF2AK3)/eukaryotic initiation factor 2 (eIF2)/ATF4 branch of the UPR (Fig. 3c). Taken together, these results suggest that HS degradation under shear promotes EC dysfunction through the activation of the UPR and in turn, CHOP-mediated apoptosis, features of unresolved ER stress. Treatment with EMPA showed attenuation of ER stress through the transcriptional downregulation of key UPR genes.
EMPA potentially attenuates inflammation through the regulation of TXNIP. In parallel to the UPR, EMPA was found to reduce the expression of the thioredoxin interacting protein (TXNIP) which impacts oxidative stress regulation and has been related to ER stress. Treatment with EMPA for 6 h in static culture was found to downregulate the mRNA expression of TXNIP (Fig. 4a, EMPA vs CTL *p < 0.05). TXNIP mRNA levels were also significantly reduced by shear after 24 h (Fig. 4b, CTL vs CTL (Static) *p < 0.001). Sustained HS degradation partially abolished the shear-induced regulation (sDEG vs CTL # p < 0.01, sDEG vs CTL (Static) $ p < 0.01) and treatment with EMPA normalized the expression by significantly reducing the increased levels caused by degradation (sDEG-EMPA vs sDEG % p < 0.05, sDEG-EMPA vs CTL (Static) *p < 0.001). Sustained HS degradation also caused a significant increase in TXNIP protein expression (Fig. 4c, sDEG vs CTL *p < 0.001) and similar to the mRNA levels, EMPA normalized the expression compared to the control (sDEG-EMPA vs sDEG # p < 0.01). This suggests that TXNIP could be a potential mediator in the ER stress response as its mRNA and protein expression was modulated by shear, sustained HS degradation and EMPA.
N-Acetyl-l-cysteine treatment reduces NB4 cell adhesion similar to EMPA. To further study the reduction in NB4 cell adhesion caused by EMPA, we sought to determine if the effect was mediated through the regulation of oxidative stress under shear and sustained HS degradation. Prior to the adhesion assay, ECs were treated with N-Acetyl-l-cysteine (NAC) during shear exposure for 24 h. Unlike EMPA, NAC did not significantly reduce the number of adhered NB4 cells compared to the control (Fig. 5 www.nature.com/scientificreports/ www.nature.com/scientificreports/ suggest that the mitigation of oxidative stress during shear exposure is a potential mechanism by which EMPAtreated ECs reduce their inflammatory response to sustained HS degradation.

Discussion
The disruption of the endothelial GCX has been associated with pathological conditions of the vasculature and impaired endothelial function making the role of a healthy GCX of interest in multiple diseases and treatment options. Normal GCX mechanotransduction helps maintain EC homeostasis through shear-regulated functions such as NO-driven vasodilation, cell barrier function and inflammatory cell transmigration. In this regard, treatment with SGLT2i has been demonstrated to improve vascular functions in vivo and in vitro in non-hyperglycemic conditions through improvement of EC homeostasis 13,17,[19][20][21]26,27 . Recent studies have demonstrated that EMPA can improve EC function but the mechanisms involved remain elusive.  www.nature.com/scientificreports/ Given the potential of EMPA to remediate EC dysfunction, we sought to study the effects of EMPA in a proinflammatory chronic GCX disruption model by using sustained HS degradation. In this study, we were able to show the impact of sustained GCX disruption on the induction of ER stress and a possible mechanistic effect of EMPA to attenuate the associated inflammatory response which could contribute to the improved vascular health observed clinically [8][9][10] .
Under normal conditions, the GCX at the apical surface of ECs allows the transduction of shear stress through the cytoplasmic membrane, transforming sensing forces into biochemical signals 28 . Thus, laminar shear stress induces the adaptive remodeling of the cytoskeleton i.e. cell elongation and the production of NO through the activation (phosphorylation Ser1177) of eNOS 29,30 . Upon disruption of the surface GCX, these transduced effects are impaired, leading ECs to a pro-inflammatory state, promoting inflammatory cell adhesion 3 . Hyperglycemic conditions have been shown to cause vascular GCX disruption in vivo 1,31 and in vitro 32 thus treatment with EMPA was studied for its potential benefits on HS integrity, which could prevent EC dysfunction.
The sustained HS degradation in our study reduced the HS mean intensity at EC surface by approximatively 85% and prevented regrowth during the 24 h culture period ( Supplementary Fig. S1) which is in line with previous in vitro studies 33,34 . EMPA did not improve HS intensity in control condition or under sustained degradation. Similarly, treatment with EMPA did not overcome the shear-induced elongation loss under sustained HS degradation ( Supplementary Fig. S2) but resulted in significantly less NB4 cells adhered to the EC surface under degraded condition (Fig. 1). Taken together, these results define the mechanosensory and anti-inflammatory role of the GCX as HS-dependent and indicate that EMPA can reduce inflammation independently of HS-mediated EC functions. www.nature.com/scientificreports/ The impact on inflammation downstream of known GCX mechanotransduction was assessed through eNOS homeostasis and ICAM-1 expression to characterize the inflammatory response of treated ECs. Degradation of HS has been linked to reduced shear-induced NO production in ECs 5,35 . Ebong et al. and others further demonstrated that the impairment of NO production is mediated through reduced phospho-eNOS Ser1177 levels and is concomitant with loss of EC remodeling 30,36 . In our case, stimulation with TNF-α resulted in significant reductions in eNOS and phospho-eNOS Ser1177 levels with no further decrease due to HS degradation, indicating that TNF-α may have eclipsed the impact of degradation on NO production (Fig. 2). Nonetheless, no improvement of phospho-eNOS/eNOS levels were found with EMPA, indicating that eNOS activation might not contribute directly to the anti-inflammatory effect of EMPA. Although we did not find significant changes in the expression level of phospho-eNOS/eNOS induced by EMPA, recent studies have shown improved NO production and EC-dependent vasodilation in response to EMPA. Treatment with 1 μM EMPA restored NO bioavailability in TNF-α stimulated cardiac microvascular ECs (CMECs) 21 19 . Moreover, reduction of inflammatory cell adhesion in a dose-dependent manner was demonstrated with Ang-II stimulated HUVECs. Expression of ICAM-1 and VCAM-1 was also found to be reduced in CMECs isolated from EMPA-treated mice 17 . Conversely, expression of ICAM-1 and VCAM-1 remained unchanged in TNF-α stimulated CMECs 21 and HCAECs 20 treated with 1 μM of EMPA. We previously showed that ICAM-1 expression correlates with NB4 cell adhesion 3 , however, the protein expression of ICAM-1 (Fig. 2) were unaffected by sustained HS degradation or EMPA suggesting that regulation of the adhesion molecule ICAM-1 may not contribute to the variations in the number of NB4 cell adhesions.
From the transcriptome analysis, genes form the PERK/eIF2/ATF4 branch of the UPR were identified as being significantly regulated by sustained HS degradation and EMPA, indicative of ER stress induction (Fig. 3). Sustained degradation caused the concomitant upregulation of ATF3 and CHOP (DDIT3), likely through the signaling cascade of eIF2α phosphorylation and ATF4 transcriptional regulation 37 . Downstream of CHOP, upregulation of GADD34 (PPP1R15A) and TRIB3 are related to the inhibitory regulation of eIF2α phosphorylation and ER stress-mediated cell apoptosis 38 , respectively. Together, these changes evoke the progressive induction of UPR due to unresolved ER stress leading to increase reactive oxygen species (ROS) production and the activation of apoptotic signaling through CHOP [39][40][41]  www.nature.com/scientificreports/ (Grp78) and ATF3) in beta cells of diabetic murine models 42 . Similar observations were made with MIN6 cells where the induction of ER stress with thapsigargin caused the degradation of intracellular HSPG and HS, suggesting a degradation mechanism at the cellular level. Moreover, shear is known to have a regulatory effect on ER stress. While laminar shear stress limits ER stress 43 , low shear or disturbed flow promote ER stress signaling with inflammation and apoptosis 44,45 . This could, in part, explain how sustained HS degradation triggers ER stress through the loss of normal laminar shear stress response. Treatment with EMPA caused small but significant reductions in the transcriptional expression of ATF3, DDIT3 (CHOP), HSPA5 (Grp78), PPP1R15A, and TRIB3 under HS degradation suggesting a dampened apoptotic response (Fig. 3). Other studies have also found similar dampening effects of EMPA on ER stress. Treatment of ApoE (−/−) and C57Bl/6 mice with EMPA for 5 weeks resulted in the reduction of hepatic ER stress as shown by the downregulation of ER stress signaling genes including HSPA5 (Grp78), ERN1 (IRE1), XBP1, DDIT3 (CHOP), ATF4, ATF6 and GADD45A and the reduced ratio of phospho-eIF2α/eIF2α 46,47 . A study by Zhou and Wu demonstrated the potency of EMPA on ER stress related cardiomyopathy of diabetic rats 48 . Treatment with EMPA for 8 weeks resulted in improved cardiac functions along with reduced cardiomyocyte apoptosis and protein expression of ER stress markers (Grp78, CHOP and cleaved caspase-12) suggesting a lesser impact of ER stress on the cardiomyocytes.
ER stress is inherently tied to oxidative stress as the adaptive protein folding is coupled to ROS production 49 . Additionally, oxidative stress can be exacerbated through the action of TXNIP which is related to ER stress by its concomitant activation. TXNIP is a critical regulator of ROS signaling implicated in diverse vascular pathologies due to its role in downstream inflammation and apoptosis. Through its inhibitory effect, TXNIP can impair the thiol-redox system thioredoxin (TRX), promoting oxidative stress. Lerner et al. demonstrated how activation of the UPR sensors, IRE1α and PERK, resulted in increased TXNIP mRNA levels and increased ROS levels in mouse embryonic fibroblasts 50 . Deletion of IRE1α, PERK or TXNIP abolished the detrimental effects associated with unresolved ER stress. Moreover, disturbed flow has been shown to upregulate TXNIP protein expression which caused increased leukocyte-EC adhesion through increased ICAM-1 and VCAM-1 expression 51 . TXNIP is also known to interact with and activate the NLRP3 inflammasome resulting in enhanced inflammation as well as promoting apoptosis through the dissociation of TRX from the apoptosis signal-regulating kinase 1 (ASK1) 52,53 .
Given the detrimental effects associated to the expression of TXNIP and its implication in ER stress, we hypothesize that it plays a regulatory role in the effects provided by EMPA. Indeed, TXNIP mRNA levels were downregulated by EMPA after 6 h in static condition (Fig. 4). Sustained HS degradation caused the loss of the shear-induced downregulation of TXNIP mRNA and an increase in TXNIP protein. EMPA respectively reduced and normalized the mRNA and protein expression, which correlates with the trend observed in NB4 cell adhesion. These results are in accordance with previous studies showing the role of shear-regulated TXNIP in the inflammatory response of HUVECs 52 and the correlation between TXNIP expression and leukocyte-endothelium adhesiveness 51 .
The transcriptomic profile of degraded samples (sDEG and sDEG-EMPA vs CTL) was also characterized by the differential regulation of redox genes (Supplementary Table S1) suggesting an adaptive response to oxidative stress. While we were unable to show the direct reduction of ROS by EMPA in static culture ( Supplementary  Fig. S3) or under shear (data not shown), a few studies have shown that SGLT2i can effectively reduce oxidative stress in different conditions. Pre-clinical studies demonstrated the potential of EMPA to reduce whole blood oxidative burst, cardiac NAPDH oxidase activity as well as aortic and endothelial ROS levels in diabetic rats 15,16 . Zhou et al. also showed reduction in intracellular and mitochondrial ROS by EMPA in CMECs isolated from diabetic rats 17 . In vitro treatment of CMECs/HCAECs with 1 μM EMPA resulted in the reduction of TNF-α induced oxidative stress as measured by intracellular and mitochondrial ROS suggesting that EMPA has a protective effect against ROS production in normoglycemic conditions while a direct anti-oxidant effect was excluded by the authors.
By virtue of its role in EC homeostasis, the disruption of the GCX also coincide with increased ROS production, promoting a vicious circle of degradation as ROS will further promote GCX disruption 54,55 . In this context, unresolved ER stress with increased TXNIP expression can cause ROS production and may result in increased NB4 cell adhesion. To test this, NAC was used to promote ROS scavenger and mitigate oxidative stress during shear exposure. Perfusion of NAC has been previously shown to prevent hyperglycemic damage of the glycocalyx 1 and to reduce the level of hyaluronan shedding during renal fluid resuscitation 56 . In our case, incubation with NAC resulted in similar reductions of adhesion compared to EMPA suggesting an oxidative stress mediated mechanism by EMPA. However, the exact impact of EMPA on the interplay between ER stress and TXNIP, resulting in reduced oxidative stress and in turn reduced inflammation, remains to be clarified. TXNIP knockout ECs could represent an interesting model to test the EMPA effect dependency on TXNIP expression.
The study of the glycocalyx in vitro as well as conclusions drawn from transcriptional data comes with inherent limitations. First, the glycocalyx of ECs in culture is known to lack the thickness of its in vivo counterpart which may lessen the impact of degradation on inflammatory cell adhesion 57 . Although different from chronic GCX disruption, sustained enzymatic degradation of HS was used as an inflammatory stimulus to mimic EC GCX shedding as found in diabetic or curved/branching vasculature. Furthermore, while the effect of HS degradation was the focus of this study, degradation of other components of the GCX can also impact EC homeostasis which could induce different signaling cascades and therefore change the role of EMPA in the restoration of GCX functions. Although the use of TNF-α under sustained HS degradation does not allow to fully dissociate their respective impact on EC inflammation in all experiments, TNF-α addition was required to perform adhesion assays and was therefore use in subsequent experiments to properly interpret the results. The single time-point studied does not reflect transient response or feedback regulation between ER stress and inflammation. Moreover, a suprapharmacological concentration of EMPA was used compared to the reported serological concentrations www.nature.com/scientificreports/ of treated patients 58 in order to study the reduction in inflammation previously reported and to highlight the potential cellular mechanisms that may occur under lower serological concentrations over longer periods of time.
In conclusion, the present study suggests a possible mechanism by which EMPA may contribute to better endothelial health. Our results point toward the potential of EMPA to attenuate EC inflammation independently of HS-mediated functions, as shown by the reduction of inflammatory cell adhesion under sustained HS degradation. Downregulation of pro-apoptotic signaling and TXNIP expression by EMPA may contribute to oxidative stress mitigation therefore limiting oxidative damage under unresolved ER stress and resulting in reduced inflammatory cell adhesion. Future work should aim at studying the regulatory mechanisms associated with the expression of TXNIP on the inflammatory response through the NLRP3 inflammasome and apoptotic signaling. A better understanding of the effects of SGLT2i on GCX-mediated EC functions could benefit new strategies to limit EC dysfunction in pathological conditions where chronic GCX damage is found.

Materials and methods
Cell culture and 3D culture model. Human abdominal aortic endothelial cells (HAAECs, ATCC, Coriell, CRL-2472) were cultured in endothelial cell growth medium (Promocell, C-22020), supplemented with 10% fetal bovine serum and 1% penicillin-streptomycin (Invitrogen) in culture flasks coated with 0.1% pig gelatin at 37 °C and 5% CO 2 . Cells were grown to confluence and harvested from the flask with TrypLE (ThermoFisher, 12605028). Experiments were performed with cells at passage 5 and 6.
Tubular cell culture models were produced as previously described 59,60 . Briefly, the silicon elastomer Sylgard™ 184 (Paisley, AVDC0184-39) was prepared by mixing the base and curing agent in a 10:1 ratio. Sylgard™ 184 was cured around a polished stainless steel rod in plexiglass molds. Following complete curing, the rod was removed, creating a straight hollow tube where cell can be seeded and grown. In preparation to cell culture, models were sterilized by boiling and coated with a 40 μg/mL human fibronectin (Akron Biotech, AK9715-0005) solution overnight. HAAECs were seeded at a concentration of 1 × 10 6 cells/mL and grown for 48 h. Models were mounted on a rotor to ensure complete and even coverage of the inner surface. Cells were then cultured for 24 h in static or shear condition (laminar shear stress of 10 dyne/cm 2 ) with or without 50 μM EMPA.
Heparan sulfate enzymatic degradation. GCX disruption was performed by enzymatic degradation of HS. HAAECs were treated with 0.5 U/mL of heparinase III (Sigma unit, enzyme 4.2.2.8, IBEX Pharmaceuticals, 50-012) in FBS-free media for 2 h followed by the addition of 0.1 U/mL in the medium during the 24 h of static or shear culture to achieve sustained degradation (sDEG) and to prevent HS regrowth. The initial condition of degradation (DEG T0) was assessed immediately after the initial 2 h exposure to heparinase III.
Heparan sulfate immunostaining and confocal microscopy. Cells were fixed in situ with a 2%/0.1% paraformaldehyde/glutaraldehyde solution in PBS for 30 min without prior washes to prevent HS disruption. Sections of the models were cut and samples were blocked with a 2% normal goat serum (NGS) in PBS. Primary antibody for HS (1:100, mouse, 10E4, Amsbio, 370255) was diluted in 1% NGS/PBS and incubated overnight at 4 °C. Cells were rinsed with PBS and incubated for 1 h with the secondary antibody (ThermoFisher, goat anti-Mouse IgG, IgM (H + L) Alexa Fluor 488, A-10680) and DAPI (1:1000) diluted in 1% NGS/PBS. Cells were rinsed with PBS and the model section were cut, mounted using 0.2% Dabco/Glycerol (1:5, Sigma) and imaged via laser scanning confocal microscopy (Zeiss Exciter 800). Z-stack images were acquired at 10 × magnification and maximum intensity projections were created to quantify the mean gray value of each image using ImageJ. Cell morphology and shape index. Following the static or shear culture with or without EMPA, cells were fixed in situ with 1% paraformaldehyde in PBS for 20 min, rinsed with PBS and stained with a 4% crystal violet (BD Biosciences) solution for 10 min. Cell morphology was assessed through light microscopy (Leica DMIL microscope and Leica DC300 camera) images and quantified by computing the shape index of individual cells using Matlab scripts 59 . The shape index (SI) is used as a metric of cell elongation where a perfectly round cell has a SI close to 1 and a straight elongated cell, a SI closer to 0. Adhesion assay. Adhesion assays were performed as previously described 24 . Acute promyelocytic leukemia (NB4) cells were cultured in suspension and maintained at a concentration of 2 × 10 5 to 1 × 10 6 cells/mL in RPMI 1640 medium with 2 mM l-glutamine supplemented with 10% FBS and 1% penicillin-streptomycin. 48 h prior to the adhesion assay, NB4 cells were stimulated with 10 -6 M all-trans-retinoic acid (ATRA, Sigma, R2625) to induce differentiation into granulocytes. Adhesion assays were conducted following 24 h of shear exposure and tumor necrosis factor-alpha (TNF-α; PeproTech, 300-01A, 10 ng/mL) stimulation of HAAECs to induce NB4 cell adhesion. As previously shown, TNF-α stimulation is necessary to reach significant numbers of NB4 cell adhesions 24 . Also, to assess the effect of oxidative stress on adhesion, HAAECs were treated with 1 mM of N-Acetyl-l-cysteine (NAC, Sigma, A9165) for 24 h prior to the adhesion assay. A NB4 cell suspension at 5 × 10 5 cells/mL was perfused through the models at a shear stress of 1.25 dyne/cm 2 for 1 h. PFA 1% was then perfused to fix the adhered NB4 cells to the endothelial monolayer while removing non-adherent NB4 cells. The number of adhered NB4 cells was determined by manually counting cells from light microscope images (3-5/ sample) at a magnification of 4 ×.
Protein collection and western blot. HAAECs were washed with cold PBS and lysed in situ in cold RIPA lysis buffer (ThermoFisher, 89900) with 2% Halt™ protease and phosphatase inhibitor cocktail (ThermoFisher, 78440). Samples were vortexed and kept on ice before centrifuging at 13,000 RPM for 10 min. Protein quanti- Transcriptome analysis. The transcriptome profiles of HAAECs under two sets of conditions were studied.
Cells were statically cultured with or without EMPA for 6 h or cultured under similar conditions to the adhesion assay (24 h shear culture, TNF-α stimulation, CTL (Static), CTL, sDEG and sDEG-EMPA). Following treatment, cells were lysed in situ and RNA isolation was performed using the RNeasy Plus Micro kit (QIAGEN) according to manufacturer instructions. Sample RNA integrity was confirmed with the RIN using a BioAnalyzer (Agilent). The genomic transcriptome profile of each sample was determined with a Human Clariom S Array and analyzed using the Transcriptome Analysis Console software (SST-RMA method, Applied Biosystems, v4.0.2). Gene lists were generated by filtering minimal threshold expression and fold changes (≤ − 1.5 or ≥ 1.5). The open-source pathway database REACTOME was used to analyze the gene lists and to identify potential pathways based on the number of matched entities 61 .
Reactive oxygen species measurement. Reactive oxygen species (ROS) production was measured using the 2′,7′-dichlorofluorescin diacetate (DCFDA) assay kit (Abcam, ab113851) according to the manufacturer instructions. Briefly, ECs were cultured in 96-well plates at a density of 30,000 cells/cm 2 and stained with 10 μM H2DCFDA for 30 min prior to treatments. Tert-Butyl hydroperoxide (TBHP) at 50 μM was used as positive control, with or without 50 μM EMPA for 6 h. Pretreatment with EMPA (preEMPA + TBHP) was also tested by incubating with EMPA for 18 h prior to the assay. TNF-α (10 ng/mL) and sDEG over 24 h were also tested. After incubation, ROS production was measured by fluorescence unit on a Berthold fluorescence microplate reader with the FITC filter set. Measurements were normalized to the control sample i.e. H2DCFDA stained cells with no TBHP or EMPA treatment.
Statistical analysis. Statistical analysis was performed using GraphPad Prism™ software. Results are presented as the mean values ± standard deviation of 3 independent experiments. Each experiment included 2-6 replicates for each condition and the mean was used in the analysis. When applicable, the normality of the data was confirmed by D' Agostino and Pearson test. Otherwise, the data was assumed to be normally distributed. Mean values were compared using t tests, one-way or two-way analysis of variance (ANOVA) followed by Bonferroni post-test with a 95% confidence interval. Statistical analysis of the transcriptome data was carried out through the Transcriptome Analysis Console software using default settings with eBayes analysis. p-values less than 0.05 were considered significant.

Data availability
The datasets generated for this study are available on request to the corresponding author.